Health professionals – please use the referral form below.

Please fill in as many fields as possible.

You may fill in the referral form online below, or download an off-line version of the form here. Some software will allow you to save a filled-in form on your computer; alternatively, print and scan or fax through to us – the contact details are on the form itself.

EmpowerRehab Referral Form

Online Referral Form

* Fields are required